Inspection·May 10, 2023

F 0684 ordered to flush the foley, unit manager to follow through with orders. Level of Harm - Actual harm Review of the physician notes dated April 7, 2023, revealed resident with urine retention with acute hematuria on April 7, 2023, maintain foley, flush and follow. Residents Affected - Few Clinical records review failed to reveal the NP's verbal order to flush Resident CL1's Foley catheter was completed. Interview with the NP was conducted on May 1, 2023, at 1:00 p.m., and reported that nursing is responsible for placing verbal orders into the resident's EMR (Electronic Medical Record). Interview with the Director of Nursing (DON), on May 1, 2023, at 1:00 p.m., revealed both nursing and NP are responsible for placing the order into the resident's EMR. The DON confirmed that there was no documented evidence that Resident CL1's Foley was flushed. The clinical records review failed to reveal documentation/follow-up of Resident CL1's hematuria on April 8, 2023. A review of the nursing progress notes dated April 9, 2023, at 10:54 a.m., revealed blood pressure taken lying at 7:45 a.m., was 83/54 mmHg. The same note stated, Hematuria continues. Interview conducted with licensed nurse Employee E4 on May 1, 2023, at 12:30 p.m., confirmed resident had hematuria on April 9, 2023, and blood pressure taken at 7:54 a.m., was 83/54 mm Hg. Employee E4 reported the physician was not informed of the continued hematuria because it was not a new condition. Employee E4 reported that the blood pressure was not relayed to the physician because the resident had a diagnosis of orthostatic hypotension and Midodrine medication was administered with therapy session occurring after administration. Review of physical therapy notes dated April 9, 2023, revealed resident rolled to the right and left with minimal assistance, supine to sit on the edge of the bed, a resident reported lightheadedness and dizziness., blood pressure was 91/60 mm Hg, heart rate (HR) was 123 BPM. After five minutes of sitting resident with no symptoms reported, attempted to transfer from the bed to a wheelchair but the resident lost balance requiring moderate assistance to recover and sit on the edge of the bed, the blood pressure was 88/58 mm Hg, and HR was 120 . Sit supine with moderate assistance, blood pressure was 106/63 mm Hg, HR 127 BPM. Interview with Physical Therapy Assistant (PTA) Employee E5 was conducted on May 1, 2023, at 1:00 p.m. Employee E5 reported that the resident was seen before lunch on April 9, 2023, for a therapy session. Employee E5 reported that she/he was not notified of the Resident's earlier vitals (low blood pressure) but she/he always check the resident's vitals during therapy sessions. Employee E5 reported that the resident was unable to transfer from the bed to the wheelchair due to weakness and loss of balance, vitals were monitored during the session. Employee E5 reported that she/he discussed the resident's low blood pressure and resting elevated heart rate with the Physiatrist (doctor who has special training in physical medicine). Employee E5 also reported that the nurse on duty was notified of the abnormal vitals of the resident. Interview with Licensed nurse Employee E4 on May 1, 2023, at 1:00 p.m., revealed Employee E5 notified her/him of the resident's low blood pressure but was not made aware of an elevated heart rate. Employee E4 reported the physician was not notified of the low blood pressure during therapy because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395332 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Center 30 West Avenue Wayne, PA 19087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm the therapist indicated the blood pressure returned to resident's baseline blood pressure. Employee E4 stated that for any significant change in a resident's condition, the primary physician, NP, or the on-call physicians need to be notified and not the rehab doctor. Employee E4 reported that the resident was last observed at 2:30 p.m. and reported the resident was ok. Residents Affected - Few Review of the Physiatrist's notes on April 9, 2023, revealed HR of 90 BPM, respiration was 19, continue occupational therapy, physical therapy, medications, and medical management with [primary physician]. Review of the progress notes dated April 9, 2023, at 4:30 p.m., revealed resident was unresponsive, and would not follow simple commands, pulse oximeter noted 91% on room air, oxygen was administered, 911 was called, MD and family were notified, resident was sent to the hospital. Review of the vitals documented on April 9, 2023, at 5:00 p.m., revealed Resident CL1's blood pressure was 79/44 mm Hg, and HR was 131 BPM. Review of the progress notes dated April 10, 2023, at 10:26 a.m., revealed resident was admitted with a diagnosis of septic shock (A widespread infection causing organ failure and dangerously low blood pressure). Review of the hospital records Discharge summary dated [DATE], revealed resident's principal problem was septic shock. Presenting problem was Acute Kidney Injury, Urinary Tract Infection with hematuria, and Sepsis due to unspecified organism. The hospital course revealed the patient presented to the hospital on April 9, 2023, and was found to be lethargic, and hypotensive and required intubation after failing a BIPAP. The patient was admitted to the Intensive Care Unit for management of septic shock. The patient arrested and passed on April 11, 2023. Review of Resident 1's hospital record revealed under section titled HPI (History of Present Illness) that the resident had a recent hospital admission March 31 to April 4, 2023 for Orthostatic Hypotension. Further review of hospital record revealed, When EMS arrived patient hypotensive 70s over 40s with fever 102.5F (farentheit). Medics unable to oxygen saturation in the field and subsequently started [resident] on nonrebreather. In ED (emergency department) [resident] tachypneic and markedly hypotensive. Additional review of hospital record revealed vitals recorded as follows; April 9, 2023 at 1659 (4:59 p.m.) pulse 144 with respiration 40 but blood pressure no reading. April 9, 2023 at 1714 (5:14 p.m.) blood pressure reading of 76/45. Vitals taken at 1730 (5:30 p.m.) recorded as pulse 124, respirations 48, and blood pressure 95/54 and oxygen saturation (oxygen level in blood) was 94%. Further review of hospital record revealed section Physical Exam subsections Procedures and Critical care the following; treatment was necessary to treat or prevent imminent or life threatening deteroriation of the following conditions: Cardiac failure, CNS(Central Nervous System) failure or compromise, respiratory failure, renal failure, sepsis, shock and dehydration. Additional review of hospital record revealed ED Provider noted indicating, [resident] was in hospital within past 10 days for issues with orthostatic hypotension. Apparently this morning the [resident] appeared to be more lethargic. On EMS arrive, [resident] found to be febrile, hypotensive. [Resident] has an indwelling Foley (catheter) in place on arrival with a very small amount of bloody urine in teh bag. On Arrival [resident] temperature is 100.2. He is tachycardi. He is markedly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395332 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Center 30 West Avenue Wayne, PA 19087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few hypotensive with an initial pressure being obtained 53 systolic manually. Upon removal of the old Foley, purulent urine was draining from the penis. A new Foley was placed and with this, a large return of purulent urine. The facility failed to ensure physician order and follow-up for hematuria was followed, and low blood pressure and elevated pulse rate were timely reported to the Resident's attending physician resulting in the harm of hospitalization, intubation, and admission to the Intensive Care Unit. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 3/22/23, 8/5/22 28 Pa Code 211.5(f) Clinical Records Previously cited 8/5/22 28 PA Code 211.10(a) Resident care policies Previously cited 8/5/22 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395332 If continuation sheet Page 4 of 4